Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 101 • Superﬁ cial Inguinal Node Dissection 1125

Rectus femoris muscle

Adductor longus muscle

Pectineus muscle

Inguinal ligament

Iliacus muscle

Genitofemoral nerve

Lateral femoral cutaneous

nerve

Psoas muscle

Tensor fasciae latae muscle

Femoral nerve

Femoral artery and vein

Sartorius muscle

Femoral sheath

Gracilis muscle

Great saphenous vein

FIGURE 101–3

1126 Section XV • Miscellaneous Procedures

2. DISSECTION

◆ Electrocautery is used to dissect down to subcutaneous tissue. Medial and lateral skin ﬂ aps

are created. Superiorly, the skin ﬂ aps should be thinner because nodal-bearing tissue may

be more superﬁ cial; as the dissection moves inferiorly toward the midthigh, the ﬂ ap can

become thicker. The medial aspect of the dissection extends to the pubic tubercle and

extends laterally to include the entire length of the inguinal ligament. The boundaries of the

dissection include the medial border of the adductor magnus muscle and the lateral border

of the sartorius muscle.

◆ All fatty tissues, which include lymph node–bearing tissue (see Figure 101-1) both above

and below the inguinal ligament, down to the external oblique fascia and the inguinal liga-

ment are swept inferiorly. Medially, fatty nodal tissue is reﬂ ected away from the spermatic

cord or round ligament, and all tissues overlying the femoral vessels, including the femoral

sheath, are carefully dissected en bloc into the specimen. Laterally, tissue anterior to the sar-

torius fascia are swept toward the specimen. Distally, as the saphenous vein dives behind

the sartorius muscle at the apex of the femoral triangle, the vein is divided (approximately

4 cm beyond the saphenofemoral junction). The tissue is swept superiorly until the fora-

men ovalis is encountered. Using a right-angled clamp, the surgeon ligates the saphenous

vein at the saphenofemoral junction and secures the vein with a 2-0 silk ligature. Posteri-

orly, the limits of dissection include tissue anterior to the fascia of the adductor muscles and

pectineus.

◆ The origin of the sartorius is identiﬁ ed and divided off the anterior superior iliac spine.

The sartorius muscle is mobilized medially and transposed to cover the femoral vessels

(Figures 101-4 and 101-5). The lateral femoral cutaneous nerve arises underneath the lat-

eral aspect of the inguinal ligament and extends obliquely over the origin of the sartorius.

Care should be taken to identify and preserve this sensory nerve to the lateral thigh. Blood

vessels entering the sartorius muscle are preserved as the muscle is mobilized medially to

cover the exposed femoral vessels in a tension-free manner. The proximal aspect of the

muscle has to be rotated for the coverage to be tension free. The tendinous end of the mus-

cle is sutured to the inguinal ligament with 3-0 absorbable sutures using interrupted verti-

cal mattress stitches. The sartorius muscle will protect the femoral vessels from exposure

and subsequent bleeding, in case of skin edge necrosis, wound infection, and tissue break-

down, especially after adjuvant radiotherapy.

3. CLOSING

◆ The wound is irrigated and two closed-suction drains are placed, one exiting medially and

one exiting laterally. If the blood supply to the skin edges appears marginal, the edges

should be trimmed back to healthy tissue. The incision is closed in two layers. The deeper

fascial layer is reapproximated with 2-0 or 3-0 interrupted absorbable sutures, and the skin

can be closed using skin staples.

CHAPTER 101 • Superﬁ cial Inguinal Node Dissection 1127

Sartorius

muscle

Incision line

FIGURE 101–4

Inguinal ligament

Lateral femoral cutaneous nerve

Genitofemoral nerve

External iliac vessels

Sutures

Femoral nerve

Sartorius muscle and

blood supply

FIGURE 101–5

1128 Section XV • Miscellaneous Procedures

STEP 4: POSTOPERATIVE CARE

◆ Postoperatively, the patient may ambulate with elastic support on the leg, as tolerated. How-

ever, when the patient is at rest, the extremity should be elevated to decrease limb edema.

The drains can be removed when the drainage decreases to 30 mL or less per 24 hours.

◆ Lymphedema can occur in more than 50% of patients who have undergone superﬁ cial

lymph node dissection. Prophylactic measures, such as elevating the leg and wearing

elastic stockings, are important means to decrease the severity and incidence of this

potential complication.

STEP 5: PEARLS AND PITFALLS

◆ The most common acute postoperative complication is cellulitis and/or wound infection.

Although prophylactic preoperative antibiotics are recommended, the infection rates can

range up to 30%.

◆ The rate of lymphocele or seroma formation ranges from 3% to 23%. The use of closed-

suction drains for a longer period of time can decrease the incidence of ﬂ uid formation

under the ﬂ aps; however, prolonged use has to be balanced with the increased potential for

wound infection.

◆ The incidence of extremity lymphedema can be decreased with the use of elastic stockings,

limb elevation, and exercise.

◆ The incidence of thromboembolic events, such as deep vein thrombosis and pulmonary

embolus, was reported to be 13.6% in a study of patients who underwent inguinal node

dissection for melanoma. Prophylaxis with intermittent pneumatic compression devices and

low-dose anticoagulants may minimize this complication.

SELECTED REFERENCES

1. Karakousis CP, Heiser MA, Moore RH: Lymphedema after groin dissection. Am J Surg 1983;145:205-208.

2. Arbeit JM, Lowry SF, Line BR, et al: Deep venous thromboembolism in patients undergoing inguinal

lymph node dissection for melanoma. Ann Surg 1981;194:648-655.

3. Johnson TM, Sondak VK, Bichakjian CK, et al: The role of sentinel node biopsy for melanoma: evidence

assessment. J Am Acad Dermatol 2006;54:19-27.

4. Health Care Center for the Homeless. Available on the Internet: www.hcch.org

1129

STEP 1: SURGICAL ANATOMY

◆ The left kidney is most commonly procured for live donor kidney transplantation because of

its longer vein and greater ease of access. However, given the basic tenet of live kidney dona-

tion, “leaving the best kidney in the donor,” the donor surgeon should be familiar with right

and left donor nephrectomy. There are many donor nephrectomy surgical techniques available

and include pure laparoscopic; hand-assisted laparoscopic; robot-assisted pure laparoscopic;

robot-assisted and hand-assisted, using either a transabdominal or retroperitoneal approach;

and of course, open nephrectomy. The donor surgeon and operating room should be equipped

to convert from a laparoscopic to an open approach at short notice. Regardless of technique

used, understanding the three-dimensional relationships of both kidneys is essential.

◆ Figure 102-1 illustrates some of the important anterior relationships of the right and left kid-

ney. Both kidneys are positioned high up in the retroperitoneum under cover of the costal mar-

gin. The body of the kidney is oriented obliquely on the diaphragm and quadratus lumborum

muscle in the long axis of the psoas. The hilum of the kidney and its contents are angled for-

ward. Although the position of the kidneys is altered with movement of the diaphragm, the

hilum of the right kidney (pushed down by the liver) lies just below the level of the transpylo-

ric plane, whereas that of the left kidney lies just above the level of the transpyloric plane,

approximately 5 cm from the midline. With such intimate association with the pancreas and

duodenum, it is easy to see how injuries can occur.

CHAPTER

102

Donor Nephrectomy

Jacqueline A. Lappin

Gastrosplenic

ligament

Lienorenal

ligament

Area for

splenic flexure

Transverse

mesocolon

FIGURE 102 –1

1130 Section XV • Miscellaneous Procedures

◆ Figure 102-2, A (anterior view) and Figure 102-2, B (posterior view) illustrate the rela-

tionship of each kidney to the pleura and rib cage. The parietal pleura reaches all the way

down to the spinous process of the 12th vertebra posteriorly and the 10th rib in the mid-

axillary line. This relationship becomes more important with a posterior approach to the

kidney.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Each kidney donor must undergo an extensive examination to determine physiologic,

psychological, immunologic, and anatomic suitability.

◆ The best kidney must be left in the donor.

◆ Surgical experience of the donor team will determine the surgical technique used in each

individual case.

◆ A preoperative bowel preparation, although not essential, can facilitate intraoperative and

postoperative management of the donor.

◆ Care should be taken to prevent dehydration of the donor as is apt to occur with preopera-

tive imaging, bowel preparation, and travel from out of town.

◆ Although donor evaluation is similar for both open and laparoscopic nephrectomy, it is

important to be familiar with the sensitivities and speciﬁ cities of preoperative imaging

techniques used in your facility.

CHAPTER 102 • Donor Nephrectomy 1131

Diaphragm

Anterior View

Costal

margin

11th rib

FIGURE 102 –2

Lung

Pleura

Partial pleura

lower edge

Posterior View

1132 Section XV • Miscellaneous Procedures

STEP 3: OPERATIVE STEPS

LAPAROSCOPIC TRANSABDOMINAL LEFT DONOR NEPHRECTOMY

◆ What follows is a description of a laparoscopic transabdominal left donor nephrectomy.

Differences in technique for pure laparoscopic and hand-assisted approaches are described.

◆ Position of the patient is shown in Figure 102-3. An alternate position is supine with rota-

tion toward a right lateral decubitus position. Addition of Trendelenburg can also be helpful.

◆ After induction of general anesthesia, preoperative antibiotics are given; an orogastric tube

and Foley catheter are placed. Thromboembolic-deterrent (TED) stockings and sequential

compression devices are applied to the lower extremities. The patient is carefully positioned

in a modiﬁ ed lateral decubitus position with the hips rotated posteriorly. An axillary roll is

placed and the arms are ﬂ exed at the elbow and padded. A second roll is placed between

the patient’s knees with the lower limb ﬂ exed at the knee. The kidney rest is elevated and

the patient is secured. Additional padded support may be applied to the patient’s right

shoulder, lower abdomen, and buttocks to facilitate intraoperative rotation of the table.

◆ The position of all the participants are illustrated (Figure 102-4). The surgeon stands on

the right side of the patient, and the camera operator, more caudad. The scrub nurse and

additional assistant stand on the patient’s left side. There are two video towers placed at the

top of the table on either side of the patient.

Lower limb flexed

The kidney rest

FIGURE 102 –3

Video tower

Head

Assistant

Scrub nurse

Feet

Camera

operator

Surgeon

Right Left

FIGURE 102 –4

CHAPTER 102 • Donor Nephrectomy 1133

1. INCISION

◆ Placement of trochars is shown in Figure 102-5. There are, however, many variations for

trochar and hand-port placement.

◆ Before placement of the pneumoperitoneum, the abdomen is marked for placement of tro-

chars and extraction incision. Each port site is inﬁ ltrated with local anesthesic, which can

facilitate a reduction in narcotic use postoperatively. The ports are placed as illustrated. A

10- or 12-mm port that is primarily used for dissection is placed at the level of the umbili-

cus, a second 10- or 12-mm camera port is placed lateral to the rectus muscle, halfway

between the umbilicus and the anterior superior iliac spine. Transillumination of the abdo-

men can be used to prevent injury to the inferior epigastric artery with this latter trochar

placement. A third 5-mm port is placed in the midline, halfway between the umbilicus and

the xiphoid process, and a fourth 5-mm port can be placed in the ﬂ ank for retraction. As

the operation progresses, the camera port and dissection ports can be interchanged to

obtain optimal exposure. Once the pneumoperitoneum is established, the zero-degree lens

camera is replaced with a 30-degree angled scope.

◆ For hand-assisted laparoscopic left nephrectomy, the umbilical port is lengthened in the

midline to facilitate placement of a pneumatic cuff or GelPort (Figure 102-6). At least two

laparotomy sponges can be introduced at this time.

5-mm port

(dissection port)

10-/12-mm port

(dissection port)

10-/12-mm port

(camera port)

Extraction

incision marked

Optional additional

flank port

FIGURE 102 –5

For hand

assist

10-/12-mm port

FIGURE 102 –6

1134 Section XV • Miscellaneous Procedures

2. DISSECTION

◆ The Harmonic scalpel or Bovie electrocautery, or both, can be used for the dissection. Be-

cause pneumoperitoneum affects renal blood ﬂ ow, a pneumoperitoneum of 12 to 14 mm Hg

is maintained. The dissection proceeds with an incision placed along the white line of Toldt.

This is extended superiorly to include takedown of the splenocolic and lienorenal ligaments

and inferiorly to the sigmoid colon and iliac vessels (Figure 102-7). The superior and lateral

attachments of the kidney helps suspend and ﬁ x the kidney to facilitate hilar dissection. The

analogy of taking the sheet off the bed has been used to describe this reﬂ ection of the colon

medially to expose Gerota’s fascia and the kidney. As with open surgery, maintaining the cor-

rect plane is essential. There is a perceptible difference in the appearance of the mesenteric

and retroperitoneal fat (mesenteric fat is a brighter yellow).

◆ Next, the gonadal vein is identiﬁ ed and traced superiorly to the renal vein, which is then

dissected out (Figure 102-8).

Lienorenal

ligament

Splenocolic

ligament

White line

of Toldt

FIGURE 102 –7

Adrenal

vein

Gonadal vein

Ureter

FIGURE 102 –8